The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?
Maintaining accurate records of intake and output
Maintaining a patent airway
Inserting a nasogastric (NG) tube as prescribed
Providing appropriate pain control
The Correct Answer is B
A. Maintaining accurate records of intake and output: While monitoring intake and output is important for assessing fluid balance and kidney function, it is not as immediate a concern as maintaining an airway in an unconscious client.
B. Maintaining a patent airway: This is the highest priority because an unconscious client is at high risk of airway obstruction due to the loss of protective reflexes. Ensuring that the airway remains open is critical to prevent respiratory distress or arrest.
C. Inserting a nasogastric (NG) tube as prescribed: Inserting an NG tube might be necessary for feeding or draining gastric contents, but it is secondary to the more urgent need of ensuring a clear airway.
D. Providing appropriate pain control: Pain control is important but should be considered after addressing more immediate threats to the client's safety, such as maintaining a patent airway.
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Related Questions
Correct Answer is D
Explanation
A. Instruct to resume regular activities such as driving. It is not safe to instruct the client to resume activities like driving immediately, especially at the beginning of lithium therapy, as lithium can cause side effects that may impair the client's ability to safely perform tasks such as driving.
B. Administer lithium before meals. Lithium is typically taken with food to minimize gastrointestinal upset. Administering it before meals may increase the risk of side effects like nausea.
C. Withhold if serum level is less than 1.5 mEq. Lithium should be withheld if the serum level is above the therapeutic range (typically 0.6–1.2 mEq/L), as higher levels can lead to toxicity. Withholding lithium if the level is less than 1.5 mEq/L is incorrect and could lead to inadequate treatment.
D. Instruct to avoid breastfeeding. Lithium is excreted in breast milk and can pose a risk to the infant, so the client should be advised against breastfeeding while on lithium therapy.
Correct Answer is C
Explanation
A. "I can see that you're uncomfortable now, so we can wait until tomorrow." Delaying the medication could worsen the client's condition and does not address the underlying reason for the refusal.
B. "If you refuse these pills, you'll have to get an injection." This response is coercive and could damage trust between the client and the nurse. It does not explore the client's concerns.
C. "What is it about the medicine that you don't like?" This response is therapeutic as it opens a dialogue with the client to understand their concerns, which can help in addressing the reluctance and promoting adherence to the medication.
D. "You know you have to take this medicine for your own good." This response is paternalistic and dismisses the client's autonomy and concerns, which may lead to further resistance.
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